Newborns

Newborn

child from birth through 28 days old

Infant

28 days to 1 year

Diagnostics

Blood samples, metabolic profile, PKU test, serum bilirubin level, glucose screening

Blood samples

drawn from the newborn to identify disorders that may affect the health of the newborn (drawn via heel stick)

Metabolic profile

errors of metabolism and blood disorders

Phenylketonuria (PKU) test

check for phenylalanine (amino acid required for normal growth and development); deficiencies could cause serious neurological and intellectual disabilities

Serum bilirubin level

if elevated, skin and sclera may turn yellow (jaundice)

Glucose screening

some newborns are at a higher risk for hypoglycemia; SGA, LGA, premature, diabetic mothers

SGA

small for gestational age

LGA

large for gestational age

Premature

born before 37 weeks gestation

Health history

include parent(s) in assessment process

cultural

COLDSPA

planned/unplanned

prenatal care

primary sources

PMH of mother

preterm labor

blood type

illnesses/infections during

TORCH infections - can cross placenta

HIV, hepatitis - cross placenta

Group B strep, gonorrhea, chlamydia - pass to newborn during labor and delivery

Meds

smoking, drinking, substance use

FH - birth defects, congenital abnormalities, cardiac abnormalities, blood disorders

Due date

Rupture of membrane

Length of labor

meds used during

agar score

Hypertension

can cause decreased placental perfusion resulting in restricted fetal growth (SGA or preterm birth)

Anemia

increased risk for preterm delivery and low birth weight

Diabetes

LGA can cause birth trauma and newborn hypoglycemia

Blood type

newborns born to mothers with any negative blood type or O type blood are at increased risk for jaundice

TORCH infections

toxoplasmosis, syphilis, varicella-zoster, parvovirus B19, rubella, cytomegalovirus, and herpes

can cross the placenta and have serious effects on the fetus

Smoking can lead to

can lead to prematurity, low birth weight, or increased risk of sudden newborn death syndrome (SIDS)

Drinking can cause

fetal alcohol syndrome (FAS); facial anomalies, deafness, heart defects, developmental delays, neurological abnormalities

Substance use can lead to

Newborn prematurity, low birth weight, drug withdrawal

Apgar score

gives a quick assessment of the newborn’s transition to extrauterine life

1-5 minutes after birth

based on

uHeart rate

uRespiratory rate

uMuscle tone

uReflex irritability

uSkin color

Preliminary steps

well lit area, warm, draft free, 

prewarmed radiant warmer

completely undressed

Assessing weight

To obtain an accurate initial weight of newborn

Normal weight

Weight range for full-term newborn is 2500g-4000g (5lbs. 8oz to 8lbs.13oz)

Average weight for full-term newborn is 3400g (7lbs. 8oz)

About 10% weight loss related to decreased fluid intake and fluid loss is expected over the first 3-4 days after delivery.

Abnormal weight

Weight is < 2,500g or > 4,000g

Weight loss of >10 % in the first 3-5 days of life

Assessing length

To obtain an initial length of newborn

Normal length

44-55cm (17-21 inches)

Abnormal length

<44cm (17 inches) or >55cm (21 inches)

Measuring chest circumference

To obtain initial measurement of newborn’s chest circumference

Normal chest circumference

30-33cm (11.8-13.8 inches)

Chest circumference is less than head circumference

Abnormal chest circumference

< 29cm or > 34cm.

Chest circumference is greater than head circumference

Measuring head circumference

To assess the newborn’s head circumference

Normal head circumference

33-35.5cm (12.5-14.5inches); 2cm larger than chest

Head is large in proportion to their body

Abnormal head circumference

Head circumference <33cm or >35.5cm; (1-2 cm) greater than chest circumference

Microcephalic

Macrocephalic

Microcephalic

abnormally small head size

Macrocephalic

abnormally large head size

Normal Temperature

36.5-37.4 C (97.7- 99.3 F)

Abnormal temperature

Below 36.5 (97.7 F), 38.0 C (100.4 F)

Where to auscultate Apical 

left nipple, at the fourth intercostal space

Normal HR

120-160 bpm

Abnormal HR

>160 - tachycardia

<100 - bradycardia

Murmur

Arrhythmia

Why may hr be altered?

Activity such as crying can increase HR to 180 bpm

Normal RR

irregular depth, rate, rhythm

short pauses between 5-10 s

30-60 br/m

chest + abdomen rise simultaneously

Abnormal RR

Apneic period

greater than 60 br/m

adventitious sounds

paradoxical respirations

color change, prolonged tachypnea

Obligate nose breathers

do not have response of opening mouth to breathe when nasal obstruction occurs

Flaring of nostrils → respiratory distress

BP

typically not measured on healthy baby

essential if baby is premature, has cardiac/renal disease

Normal BP range

new born - 50-75/30-45 mm Hg

full term - 72/42

Shivering

newborns not able to shiver, ineffective thermoregulation

What do you inspect during general assessment

stand at side

uActivity level               

uDeep sleep

uLight sleep

uDrowsy

uQuiet alert

uActive alert

uCrying

uResting posture

uMuscle tone

How to test jaundice

by pressing one finger on the newborn’s head, nose, or sternum; skin will appear yellow when you release pressure

Acrocyanosis

blue hands and feet (normal first 24 – 48 hours of life due to newborn being cold)

Mottled

lacy pattern of dilated blood vessels; may be noted if newborn is chilled

Post tern newborn skin

peeling, dry, cracked skin

Preterm newborn skin

lanugo, vernix caseosa 

Lanugo

fine hair covering the body (head, back, and shoulders) decreases with advancing age

Vernix caseosa

thick cheese-like coating may be present at birth, especially in the folds

Milia

pearly white cysts from sebaceous glands; often on nose

Nevus simplex (stork bites)

capillaries close to surface of the skin

Mongolian spots

bluish-black pigmented areas; sacral area

Hemangioma

“Strawberry Mark”-harmless growth/tumor of tiny blood vessels

Café au lait spots

permanent flat patches; tan to light brown

Nevus flammeus

(port-wine stain)capillary malformation just below the surface of the skin; red/purple, doesn’t blanche, permanent

Erythema toxicum

benign newborn rash, yellow/white papules/pustules with red base

Abnormal findings of skin

Jaundice, Pale color, central cyanosis, petechiae, bruising, lesions

Jaundice

associated with anemia and hepatosplenomegaly

Pale/Mottled skin

may indicate poor perfusion or poor thermoregulation

Central cyanosis

indicative of hypoxia, pulmonary disease, or congenital heart malformations

Petechiae

a result of birth injury, infection, or blood disorder

Normal head findings

Normocephalic and symmetric

Anterior fontanel - soft and flat (usually closes by 18 mos.)

Posterior fontanel-may be nonpalpable (usually closes by 2 mos.)

Sutures may be separated, approximated or overriding

Shape of head: Round or molding

Caput succedaneum

fetal scalp edema

Position of eustachian tube and proximity of nasopharynx

higher risk of ear infections

What reflexes are tested

rooting, sucking, gag

Epstein’s pearls

small cysts on the roof of the mouth formed when the palate fused

Webbing

skin folds appear as loose folds of skin

May indicate Down/Turner syndrome

Blanche test performed

on sternum

Important to palpate clavicles for

any breakage that occurred during birth

Galactorrhea

milky white discharge caused by high maternal estrogen levels; considered normal

Bowel sounds should be present

1-2 hours after birth

Normal umbilical findings 

2 a, 1 v, no odor, no drainage, no redness, inflammation

Umbilical cord

appear moist and jelly-like within the first 24 hours of birth, after that it will begin to shrivel and dry

Pain scales

Neonatal Infant Pain Scale

Neonatal Facial Coding System

Behavioral cues for pain

Facial expression

Cry

Breathing patterns

Body Movements (arms & legs)

State of arousal

Hydration status

breastfed? Formula fed?

Amount of milk taken?

Frequency

Toleration

Weight gain/loss

voiding pattern - wet diapers/stools - weight dry and wet

Normal breast fed findings

Nurses well on at least one breast every 1.5- 3 hours

Appears satiated after

Presence of 6-8 wet diapers a day

Has at least 2-3 stools/day

Stool will be loose, yellow and seedy

Normal formula fed findings

Feeds approximately 2 oz of formula every 3-4 hours

Presence of 6-8 wet diapers a day

Has at least 2-3 stools/day

Stool will be a shade of brown, soft, pasty

Uric acid crystals

pink to dark pink staining in the diaper related to concentrated urine

dehydration

You are assessing a newborn’s skin. What is a true statement about a newborn’s skin?

Skin varies dependent on length of pregnancy.

You are taking a health history. What is the first history that you should document?

Prenatal

You are palpating a newborn’s head for the first time. You palpate overriding sutures. What is your next step?

Continue the assessment and palpate the posterior fontanels